A nurse is conducting a mental status examination. Which of the following questions should the nurse ask to determine the client's insight?

A. Assess the need for physical restraints:
Assessing the need for physical restraints is not the first action to take in this situation. Physical restraints should only be considered as a last resort when there is an immediate threat to the patient or others. It's essential to attempt verbal de-escalation techniques and other non-coercive interventions before considering physical restraints.

B. Discuss the purpose of the medication with the client:
Discussing the purpose of the medication is an important step, as it can help the client understand why they are being asked to take it. However, it may not be the first action to take, especially if the client is highly agitated or manic. Attempting verbal de-escalation techniques, such as calming communication and active listening, should precede discussing the medication's purpose.

C. Stop the newly licensed nurse from administering the medication:
Stopping the newly licensed nurse from administering the medication without addressing the situation directly doesn't resolve the issue. It's important to equip the nurse with appropriate communication skills to handle the situation effectively. Preventing the administration of the medication is not the primary step; it's more about helping the nurse manage the situation appropriately.

D. Demonstrate how to verbally de-escalate the situation:
This is the recommended first action. Demonstrating verbal de-escalation techniques is crucial when dealing with an agitated or manic patient. The nurse manager can model effective communication strategies to help the newly licensed nurse manage the situation without resorting to physical interventions or restraints. Effective verbal de-escalation can lead to a more peaceful resolution and, ideally, the patient's acceptance of the medication without confrontation.

A. The nurse maintains confidentiality unless the client's safety is compromised:
Explanation: Maintaining confidentiality is a fundamental principle in nursing practice. Nurses are ethically and legally obligated to keep client information confidential, ensuring that the client's privacy is respected. Confidentiality builds trust between the nurse and the client, encouraging open communication. However, confidentiality can be breached if the client's safety is at risk, such as if they express suicidal or homicidal thoughts, indicating the need for intervention to ensure their well-being.

B. The nurse seeks to spend extra time specifically with the client each day:
Explanation: While it's important for nurses to spend adequate time with each client, seeking to spend extra time specifically with one client may create imbalances in care distribution. Nurses should strive to provide equitable care to all clients, addressing their needs based on assessments and care plans. Special attention to one client could lead to feelings of favoritism or neglect among other clients, affecting the therapeutic environment.

C. The client sees the nurse as an authority figure:
Explanation: Clients often view nurses as authority figures due to their expertise and role in healthcare. This perception can facilitate a therapeutic relationship, as clients may trust the nurse's guidance and care. However, this should be balanced with empathy and understanding to create a supportive and therapeutic environment.

D. The client regards the nurse as a friend:
Explanation: While a therapeutic nurse-client relationship aims for trust and rapport, it is not a friendship. The nurse maintains professional boundaries to provide objective care without personal bias. Friendship implies a level of personal involvement that can compromise the nurse's ability to make objective clinical decisions. A therapeutic relationship is built on trust, respect, empathy, and clear professional boundaries.